By signing this consent, I am authorizing my physician and/or other individuals he or she deems appropriate to perform and/or order exams, tests,
procedures, and any other care deemed necessary or advisable for the diagnosis and treatment of my medical condition. This consent is valid for each visit
I make to Pro-Care Medical Center unless revoked by me orally or in writing. I understand that the practice uses audio recording of patient encounters and
unrecorded live video feeds of rehabilitation treatment from time-to-time solely for educational and training purposes within the practice and I consent to
audio recording and unrecorded live video of my patient encounters for this purpose.

Please be informed Texas law allows a patient to be tested for possible exposure to the Human Immunodeficiency Virus (HIV), the virus associated with
AIDS, in the following situations: 1) to screen blood, blood products, organs or tissues to determine suitability for donation; 2) if another individual is
accidentally exposed to a patient’s blood or body fluids, such as through a needle stick (any such test shall be conducted pursuant to Pro-Care Medical
Center’s infectious disease protocol); or 3) if a medical or surgical procedure is to be performed which could expose health care workers to the patient’s
blood or body fluids. This disclosure is to inform you that you may be tested, at the expense of Pro-Care Medical Center if any of these situations occur
during your treatment period.

A Notice of Privacy Practices (NPP) is available to all patients. This Notice of Privacy Practices identifies: 1) how medical information about you may be
used or disclosed; 2) your rights to access your medical information, amend your medical information, request an accounting of disclosures of your medical
information, and request additional restrictions on our uses and disclosures of that information; 3) your rights to complain if you believe your privacy rights
have been violated; and 4) our responsibilities for maintaining the privacy of your medical information.
The undersigned certifies that he/she has read the foregoing, has access to a copy of the Notice of Privacy Practices, and is the patient, or the patient’s
personal representative.

As a part of our professional relationship, it is important that you have an understanding of our financial policy.

  • It is your responsibility to provide us with your most current insurance and billing information. We must emphasize that, as medical providers, our
    relationship is with you, the patient, and not your insurance company. Your insurance is a contract between you, your insurance company, and possibly
    your employer. It is your responsibility to know and understand the level of services covered by your insurance company.
  • If you have Medicaid coverage of any kind, you must notify us prior to your visit. This is part of your agreement with Medicaid, and failure to notify us of
    Medicaid coverage will result in full financial responsibility for services rendered.
  • We may accept assignment of insurance after verification of your coverage. Please be aware that some or perhaps all of the services provided may not
    be covered in full by your insurance company. You are financially responsible for services not covered by your insurance company.
  • We charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of
    usual and customary rates.
  • Copayments, coinsurance, and/or deductibles are due at the time of service. We will estimate the amount you owe based on information we receive
    from your insurance company; however, you are responsible for paying the full amount determined by your insurance company once they have paid your
    claim regardless of our estimation.
  • We will send a statement (to the address you provide) notifying you of any balances you may owe. If you have any questions or dispute the validity of
    this balance, it is your responsibility to contact our business office within 30-days after receipt of the initial statement. You can call (512) 371-7478 or
    (210) 881-0630. Payment in full is due upon receipt of the statement. Patient balances not paid in full within 30 days of the statement issue date are
    deemed past due. Past due accounts may be referred to a professional collection agency and/or attorney for further collection activity. You will be
    responsible to pay all collection costs incurred, including attorney’s fees and court costs if applicable.
  • In the event you submit payment by check and the bank returns the check unpaid for any reason, we will add $35.00 to your original balance. In addition, we may seek all additional legal remedies provided to us under Texas law.

We may charge you a fee if you fail to attend, cancel, or reschedule your appointment with less than one full business day’s notice. Cancellation fees are $40 for medical and Ideal Protein, $20 for chiropractic, and $200 for any procedures